A physical exam for your patient with headaches

A comprehensive headache exam includes a thorough physical assessment as well! Get the details here.
Last update26th Nov 2020

In general, most patients with headaches have relatively normal examinations. However, here we review some potential findings that should make you think of a more sinister etiology for your patient’s headache.

Figure 1. Vital signs are an important part of any physical examination. Headache can be caused by abnormal blood pressure, temperature, or heart rate.

Vital signs

The whole body can contribute to headache in some patients. Vital signs are an important part of any physical examination. An abnormality in blood pressure, temperature, and heart rate can contribute to headaches.

Blood pressure

Cerebral blood flow is proportionally linked to blood pressure. When blood pressure increases, the intracranial blood volume is increased which increases intracranial pressure, resulting in headaches (particularly during a hypertensive crisis). More importantly, a sudden severe headache with elevated blood pressure may be indicative of a hemorrhagic stroke. Uncontrolled hypertension can cause blood vessels to rupture resulting in hemorrhage.

Temperature

An elevated body temperature can be associated with systemic illness. For example, an infection like meningitis can produce a headache.

Heart rate

Changes in heart rate and rhythm can also indicate various medical illnesses that may produce secondary headache, such as atrial fibrillation with stroke. Tachycardia can be an indication of infection, other medical illness, or it could just be a marker for severe pain from the headache.

Figure 2. When assessing a patient with headache, auscultation of heart, lungs, carotid arteries and eyes can provide information about a patient’s general health, ventilation status and the presence of vascular disease.

Cardiac and respiratory evaluation

Auscultation of the heart may give clues to general health and the presence of vascular disease.

Examination of the lungs can give clues about ventilation and uncover underlying infection.

Auscultate the carotid arteries and the eyes for bruits.

Palpate the temporal arteries for ropiness and to assess the pulse which may be lost in temporal arteritis.

Head and neck

Observation and palpation of the head and neck of a patient with headache will help to identify trigger points, trauma, infection, and disorders of the glands or joints in this region.

Trigger points

The sinuses and muscles of the head and neck must be palpated to look for tender areas. Are there any trigger points in the strap muscles or temporalis muscles? Also assess for active trigger points in the muscles of the neck, and around the shoulders, including the rhomboids and trapezius. This search may lead the skilled examiner to extend the examination into the upper extremities and torso.

Trauma or infection

Check for signs of trauma or infection. Check the range of motion of the cervical spine and stress the facets and ligaments by hyperextending the neck while the head is bent to each side. If there is any restricted range of motion that is deemed to indicate nuchal rigidity, this may indicate meningeal irritation from blood or infection.

Thyroid gland

Palpate the thyroid gland for nodules and enlargements.

Figure 3. Palpate the thyroid gland for nodules and enlargements during the physical examination of a patient with headache.

Temporomandibular joint

Lastly, palpate the temporomandibular joint (TMJ) during opening and closing. Is there a click? Does the mandible slide or translocate? Does the jaw open widely?

Figure 4. Palpation of the temporomandibular joint (TMJ) during opening and closing to identify sliding or translocation of the mandible.

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Recommended reading

  • Donohoe, CD. 2013. The role of laboratory testing in the evaluation of headache. Med Clin North Am. 97: 217–224. PMID: 23419622
  • Ferguson, LW and Gerwin, R. 2005. Clinical Mastery in the Treatment of Myofascial Pain. Baltimore: Lippincott Williams & Wilkins.
  • Fernández-de-las-Peñas, C, Arendt-Nielsen, L, and Gerwin, R. 2010. Tension-Type and Cervicogenic Headache—Pathophysiology, Diagnosis and Management. Sudbury: Jones and Bartlett Publishers.
  • Goadsby, PJ and Silberstein, SD. 1997. Headache. Boston: Butterworth-Heinemann.
  • Goadsby, PJ, Silberstein, SD, and Dodick, DW. 2005. Chronic Daily Headache for Clinicians. Hamilton: BC Decker.
  • Lester, MS and Liu, BP. 2013. Imaging in the evaluation of headache. Med Clin North Am. 97: 243–265. PMID: 23419624
  • Rizzoli, P and Mullally, WJ. 2018. Headache. Am J Med. 131: 17–25. PMID: 28939471 
  • Silberstein, SD, Lipton, RB, and Goadsby, PJ. 2002. Headache in Clinical Practice. 2nd edition. London: Martin Dunitz.
  • Young, WB, Silberstein, SD, Nahas, SJ, et al. 2011. Jefferson Headache Manual. New York: Demos Medical Publishing.

About the author

Robert Coni, DO EdS
Neurohospitalist, Medical Director and Coordinator at the Grand Strand Medical Center, and Clinical Assistant Professor at the University of South Carolina.
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